Racial disparity in the utilization of multiparametric MRI-ultrasound fusion biopsy for the detection of prostate cancer

Sociodemographic disparities in prostate cancer imaging

Imaging is central to the diagnosis, staging, treatment planning, and monitoring of prostate cancer (PCa). Unequal access to new imaging techniques may directly contribute to gaps in PCa treatment and outcome. Thus, identifying disparities in PCa diagnosis and treatment are centrla to informing strategies to promote equitable cancer care. This review examines the existing evidence regarding clinical and sociodemographic factors associated with disparities in imaging utilization and treatment for PCa. Major areas of disparities identified include healthcare and research access. Sociodemographic disparities are present in screening and diagnosis; Black patients are consistently less likely to receive both prostate multiparametric MRI and timely molecular imaging used to evaluate for biochemical recurrence. Regional variation in appropriate and inappropriate diagnostic imaging also contributes to corresponding differences in outcomes, especially between urban and rural settings. Delays in PCa imaging and diagnosis also delay definitive treatment or placement on active surveillance, with prominent differences by race and measures of social advantage Recognition of these disparities in PCa imaging and treatment can reinforce actions to improve equitable access to patients affected by PCa. Identifying modifiable steps in the PCa diagnosis, staging, and treatment workflow may inform interventions to bridge gaps in cancer outcome.

Magnetic resonance imaging-ultrasound fusion guided focal cryoablation for men with intermediate-risk prostate cancer

INTRODUCTION

Focal therapy (FT) is a form of ablative treatment offered to men with localized, organ-confined prostate cancer (CaP). Pelvic multiparametric magnetic resonance imaging (mpMRI) and mpMRI/transrectal ultrasound fusion (MRI-US) guidance enable the precise delivery of FT with limited ablation of adjacent benign tissue or vital genitourinary structures. This article presents our findings on using MRI-US to perform FT as a primary treatment for men with intermediate-risk CaP.

METHODS

Thirty-six men underwent MRI-US fusion-guided FT cryoablation at a single center from 2018 to 2023 as a primary treatment for intermediate-risk CaP. Following FT, quarterly prostate-specific antigen (PSA) testing and a 6 to 9 month mpMRI and combined MRI-US targeted and systematic biopsy were performed. Oncological outcomes were determined using several endpoints containing biochemical recurrence, imaging failure, and pathological failure. Functional outcomes were measured using reported erectile dysfunction/potency rates, urinary incontinence rates, and the American Urologic Association Symptom Score (AUA-SS) and Sexual Health Inventory for Men (SHIM) indices.

RESULTS

Median follow-up was 29.1 months, most (75%) of whom had grade group 2 CaP. Out of the 36 men, 32 (88.9%) completed the combined MRI-targeted and systematic biopsy follow-up after treatment. The study had no major complications, but 12 (33.3%) patients experienced Clavien-Dindo grade II or lower complications. For oncological outcomes, 6 (16.7%) men had biochemical recurrence, 9 (25%) showed imaging failure, and 8 (22.2%) met the criteria for positive biopsy- out-of-field vs. in-field. 88.2% of previously potent patients remained potent postoperatively at 12 months. All patients were continent at 12 months. There were no statistically significant changes in the AUA-SS and SHIM scores postoperatively.

CONCLUSION

MRI-US-guided cryoablation to target lesions in intermediate-risk CaP appears to be a safe treatment option, with functional outcomes indicating minimal short and intermediate-term morbidity and acceptable oncological outcomes. However, despite close monitoring and follow-up, there is still a limitation in accurately predicting/detecting pathological failure after FT. The long-term durability of FT for intermediate-risk, organ-confined CaP remains uncertain.

Prostate Cancer Foundation Screening Guidelines for Black Men in the United States

BACKGROUND

In the United States, Black men are at highest risk for being diagnosed with and dying from prostate cancer. Given this disparity, we examined relevant data to establish clinical prostate-specific antigen (PSA) screening guidelines for Black men in the United States.

METHODS

A comprehensive literature search identified 1848 unique publications for screening. Of those screened, 287 studies were selected for full-text review, and 264 were considered relevant and form the basis for these guidelines. The numbers were reported according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines.

RESULTS

Three randomized controlled trials provided Level 1 evidence that regular PSA screening of men 50 to 74 years of age of average risk reduced metastasis and prostate cancer death at 16 to 22 years of follow-up. The best available evidence specifically for Black men comes from observational and modeling studies that consider age to obtain a baseline PSA, frequency of testing, and age when screening should end. Cohort studies suggest that discussions about baseline PSA testing between Black men and their clinicians should begin in the early 40s, and data from modeling studies indicate prostate cancer develops 3 to 9 years earlier in Black men compared with non-Black men. Lowering the age for baseline PSA testing to 40 to 45 years of age from 50 to 55 years of age, followed by regular screening until 70 years of age (informed by PSA values and health factors), could reduce prostate cancer mortality in Black men (approximately 30% relative risk reduction) without substantially increasing overdiagnosis.

CONCLUSIONS

These guidelines recommend that Black men should obtain information about PSA screening for prostate cancer. Among Black men who elect screening, baseline PSA testing should occur between ages 40 and 45. Depending on PSA value and health status, annual screening should be strongly considered. (Supported by the Prostate Cancer Foundation.).

Disparities in Diagnostic Imaging for Initial Local Staging for Rectal Cancer

OBJECTIVE

To assess the presence, quality, and timeliness of initial staging imaging for rectal cancer patients, and to evaluate demographic factors associated with disparities.

METHODS

We conducted a chart review of consecutive rectal adenocarcinoma cancer registry cases from a single institution for the period from 2015 to 2020. We recorded whether initial staging MRI or endoscopic ultrasound (EUS) was performed, and whether it was performed in or outside the institution. MRI quality was assessed based on compliance to the Society of Abdominal Radiology rectal cancer disease-focused panel protocol recommendations. The times between diagnosis and imaging were calculated. Patients' age, race, ethnicity, sex, body mass index, address, and primary payer were acquired from the electronic medical record. Descriptive analysis, odds ratios, and Student's t tests were used for analysis.

RESULTS

Of 346 patients, 39% were female, and the average age was 59 years. A total of 93 patients (26.8%) had no initial staging MRI or endoscopic ultrasound. Of the 142 MRIs evaluated for image quality, 100 patient exams (72.4%) met the criteria for adequate quality. The mean time interval from diagnosis to imaging was 30.9 days. A lower likelihood of receiving initial local staging was associated with being of Hispanic ethnicity (P < .01), having Medicaid or no insurance (P < .01), and residing in a low-income census block (P < .01). Higher quality of imaging was associated with residence in a census block with high median income (P < 0.01), more recent diagnosis (P < .01), and MRI performed at the institution presented (P < .01).

CONCLUSIONS

Although radiologic workup variability was found across all demographics, sociodemographic factors have an effect on local initial imaging of rectal cancer, emphasizing the need to improve image acquisition for underserved patients and improve quality standardization at low-volume centers.

Prostate Cancer, Race, and Health Disparity: What We Know

ABSTRACT

Prostate cancer (PCa) in African American men is one of the most common cancers with a great disparity in outcomes. The higher incidence and tendency to present with more advanced disease have prompted investigators to postulate that this is a problem of innate biology. However, unequal access to health care and poorer quality of care raise questions about the relative importance of genetics versus social/health injustice. Although race is inconsistent with global human genetic diversity, we need to understand the sociocultural reality that race and racism impact biology. Genetic studies reveal enrichment of PCa risk alleles in populations of West African descent and population-level differences in tumor immunology. Structural racism may explain some of the differences previously reported in PCa clinical outcomes; fortunately, there is high-level evidence that when care is comparable, outcomes are comparable.

How We Got Here: The Legacy of Anti-Black Discrimination in Radiology

Current disparities in the access to diagnostic imaging for Black patients and the underrepresentation of Black physicians in radiology, relative to their representation in the general U.S. population, reflect contemporary consequences of historical anti-Black discrimination. These disparities have existed within the field of radiology and professional medical organizations since their inception. Explicit and implicit racism against Black patients and physicians was institutional policy in the early 20th century when radiology was being developed as a clinical medical field. Early radiology organizations also embraced this structural discrimination, creating strong barriers to professional Black radiologist involvement. Nevertheless, there were numerous pioneering Black radiologists who advanced scholarship, patient care, and diversity within medicine and radiology during the early 20th century. This work remains important in the present day, as race-based health care disparities persist and continue to decrease the quality of radiology-delivered patient care. There are also structural barriers within radiology affecting workforce diversity that negatively impact marginalized groups. Multiple opportunities exist today for antiracism work to improve quality of care and to apply standards of social justice and health equity to the field of radiology. An initial step is to expand education on the disparities in access to imaging and health care among Black patients. Institutional interventions include implementing community-based outreach and applying antibias methodology in artificial intelligence algorithms, while systemic interventions include identifying national race-based quality measures and ensuring imaging guidelines properly address the unique cancer risks in the Black patient population. These approaches reflect some of the strategies that may mutually serve to address health care disparities in radiology. ^© RSNA, 2023 See the invited commentary by Scott in this issue. Quiz questions for this article are available in the supplemental material.

Racial Disparities and Mental Health Effects Within Prostate Cancer

Disparities in prostate cancer (PCa) exist at all stages: screening, diagnosis, treatment, outcomes, and mortality. Although there are a multitude of complex biological (e.g., genetics, age at diagnosis, PSA levels, Gleason score) and nonbiological (e.g., socioeconomic status, education level, health literacy) factors that contribute to PCa disparities, nonbiological factors may play a more significant role. One understudied aspect influencing PCa patients is mental health related to the quality of life. Overall, PCa patients report poorer mental health than non-PCa patients and have a higher incidence of depression and anxiety. Racial disparities in mental health, specifically in PCa patients, and how poor mental health impacts overall PCa outcomes require further study.

Substantial Gleason reclassification in Black men with national comprehensive cancer network low-risk prostate cancer - A propensity score analysis

BACKGROUND

Emerging evidence suggests that a subset of Black men with National Comprehensive Cancer Network (NCCN) low-risk prostate cancer (PCa) may harbor high volume and genomically aggressive disease. However, limited, and ambiguous research exist to evaluate the risk of extreme Gleason reclassification in Black men with low-risk PCa.

METHODS

This retrospective cohort study included 45,674 low-risk PCa patients who underwent prostatectomy and were not on active surveillance, from National Cancer Database (NCDB). A propensity score matched-pair design was employed, and the final cohort was limited to 1:1 matched 12,340 patients. Gleason score reclassification was used as primary endpoint. As such, any migration to pathologic Gleason score ≥7(3 + 4) was identified as overall, whereas migration to ≥7(4 + 3) was defined as extreme reclassification. A conditional Poisson regression model was used to estimate the risk of reclassification. Whereas spline model was used to estimate the impact of increasing time to treatment as a non-linear function on Gleason reclassification between race group.

RESULTS

Upon matching there were no differences in the baseline characteristics between race groups. In a matched cohort, higher proportion of low-risk Black men (6.6%) reported extreme reclassification to pathologic Gleason score than White men (5.0%), p < 0.001. In a conditional Poisson regression model adjusted for time to treatment, the risk of overall (RR = 1.09, 95% CI, 1.05-1.13, p < 0.001) and extreme (RR = 1.30, 95% CI, 1.12-1.50, p = 0.004) reclassification was significantly higher in Black men as compared to their White counterpart. In spline model, the probability of Gleason reclassification in Black men was elevated with increasing time to treatment, especially after 180 days (53% vs. 43% between Black and White men).

CONCLUSION

Risk of Gleason score reclassification is disparately elevated in Black men with low-risk PCa. Furthermore, time to treatment can non-linearly impact Gleason reclassification in Black men.

Mediators of Racial Disparity in the Use of Prostate Magnetic Resonance Imaging Among Patients With Prostate Cancer

Importance

Racial disparity in the use of prostate magnetic resonance imaging (MRI) presents obstacles to closing gaps in prostate cancer diagnosis, treatment, and outcome.

Objective

To identify clinical, sociodemographic, and structural processes underlying racial disparity in the use of prostate MRI among men with a new diagnosis of prostate cancer.

Design, Setting, and Participants

This population-based cohort study used mediation analysis to assess claims in the US Surveillance, Epidemiology, and End Results (SEER)-Medicare database for prostate MRI among 39 534 patients with a diagnosis of localized prostate cancer from January 1, 2011, to December 31, 2015. Statistical analysis was performed from April 1, 2020, to September 1, 2021.

Exposure

Diagnosis of prostate cancer.

Main Outcomes and Measures

Claims for prostate MRI within 6 months before or after diagnosis of prostate cancer were assessed. Candidate clinical and sociodemographic meditators were identified based on their association with both race and prostate MRI, including the Index of Concentration at the Extremes (ICE), as specified to measure racialized residential segregation. Mediation analysis was performed using nonlinear multiple additive regression trees models to estimate the direct and indirect effects of mediators.

Results

A total of 39 534 eligible male patients (3979 Black patients [10.1%] and 32 585 White patients [82.4%]; mean [SD] age, 72.8 [5.3] years) were identified. Black patients with prostate cancer were less likely than White patients to receive a prostate MRI (6.3% vs 9.9%; unadjusted odds ratio, 0.62, 95% CI, 0.54-0.70). Approximately 24% (95% CI, 14%-32%) of the racial disparity in prostate MRI use between Black and White patients was attributable to geographic differences (SEER registry), 19% (95% CI, 11%-28%) was attributable to neighborhood-level socioeconomic status (residence in a high-poverty area), 19% (95% CI, 10%-29%) was attributable to racialized residential segregation (ICE quintile), and 11% (95% CI, 7%-16%) was attributable to a marker of individual-level socioeconomic status (dual eligibility for Medicare and Medicaid). Clinical and pathologic factors were not significant mediators. In this model, the identified mediators accounted for 81% (95% CI, 64%-98%) of the observed racial disparity in prostate MRI use between Black and White patients.

Conclusions and Relevance

In this this population-based cohort study of US adults, mediation analysis revealed that sociodemographic factors and manifestations of structural racism, including poverty and residential segregation, explained most of the racial disparity in the use of prostate MRI among older Black and White men with prostate cancer. These findings can be applied to develop targeted strategies to improve cancer care equity.

Patient Race or Ethnicity and the Use of Diagnostic Imaging: A Systematic Review

OBJECTIVE

To summarize the existing literature evaluating differences in imaging use based on patient race and ethnicity.

METHODS

The authors performed a structured search of four databases for the dates January 1, 2000, to April 13, 2021, using key words and derivatives focused on imaging and patient race. Retrieved citations were reviewed by abstract and then full text to identify articles that evaluated the likelihood of imaging use by patient race or ethnicity controlling for sociodemographic factors. Data regarding publication characteristics, study population, clinical setting, and results was extracted and summarized.

RESULTS

The structured search identified 2,938 articles of which 206 met inclusion criteria. Most studies (87%, 179 of 206) were conducted in the United States, and the majority (72%, 149 of 206) found decreased or inappropriate imaging use in minority groups. Breast cancer screening was the most common clinical setting (50%, 104 of 206), followed by cancer care (10%, 21 of 206) and general imaging use (9%, 19 of 206). Government-administered surveys were the most common data source (40%, 82 of 206). Only a small minority of studies (8%, 17 of 206) evaluated strategies to mitigate the unequal use of imaging based on patient race and ethnicity.

DISCUSSION

The existing literature shows decreased or inappropriate use of diagnostic imaging for minority patients across a wide variety of clinical settings. Although the number of articles on the topic is large, the majority are clustered around specific topics, and few articles evaluate potential strategies to reduce the inequitable use of diagnostic imaging.

Health Care Disparities in Radiology-A Review of the Current Literature

INTRODUCTION

Health care disparities exist in all medical specialties, including radiology. Raising awareness of established health care disparities is a critical component of radiology's efforts to mitigate disparities. Our primary objective is to perform a comprehensive review of the last 10 years of literature pertaining to disparities in radiology care. Our secondary objective is to raise awareness of disparities in radiology.

METHODS

We reviewed English-language medicine and health services literature from the past 10 years (2010-2020) for research that described disparities in any aspect of radiologic imaging using radiology search terms and key words for disparities in OVID. Relevant studies were identified with adherence to the guidelines set forth by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement.

RESULTS

The search yielded a total 1,890 articles. We reviewed the citations and abstracts with the initial search yielding 1,890 articles (without duplicates). Of these, 1,776 were excluded based on the criteria set forth in the methods. The remaining unique 114 articles were included for qualitative synthesis.

DISCUSSION

We hope this article increases awareness and inspires action to address disparities and encourages research that further investigates previously identified disparities and explores not-yet-identified disparities.

Racial and Socioeconomic Disparities in MRI-Fusion Biopsy Utilization to Assess for Prostate Cancer

OBJECTIVE

To evaluate whether racial disparities in MRI-Bx usage persisted after correction for socioeconomic, demographic, and clinical factors.

METHODS

This is a retrospective cohort study of patients who received either MRI-Bx or systematic biopsy (SB) within a single academic medical center between January 2018 - June 2020. For each patient, socioeconomic variables including household income, education, percent below poverty, and unemployment were estimated using 2015 American Community Survey census-tract level data. Chi-square analysis was used to examine differences in clinical and demographic characteristics between the two groups. The Benjamini-Hochberg procedure was used to control false discovery rate (FDR) for multiple testing.

RESULTS

Eighteen percent of Black men (53/295) received MRI-Bx while 41% (228/561) of white men received MRI-Bx. Patients coming from highly impoverished areas were less likely to receive MRI-Bx, 25% versus 75%, respectively. In multivariate analysis, race remained significantly different across MRI-Bx and SB groups. Clinical factors including family history, DRE, BMI, and prostate volume were not significantly different between patients receiving MRI-Bx and SB.

CONCLUSIONS

Black men are less likely to receive MRI-Bx than white men, even after adjusting for clinical and socioeconomic characteristics. Further work is necessary to identify and study methods to increase equity in PCa diagnostic testing.

Association Between Motor Task Performance and Hippocampal Atrophy Across Cognitively Unimpaired, Amnestic Mild Cognitive Impairment, and Alzheimer's Disease Individuals

Hippocampal atrophy is a widely used biomarker for Alzheimer's disease (AD), but the cost, time, and contraindications associated with magnetic resonance imaging (MRI) limit its use. Recent work has shown that a low-cost upper extremity motor task has potential in identifying AD risk. Fifty-four older adults (15 cognitively unimpaired, 24 amnestic mild cognitive impairment, and 15 AD) completed six motor task trials and a structural MRI. Several measures of motor task performance significantly predicted bilateral hippocampal volume, controlling for age, sex, education, and memory. Thus, this motor task may be an affordable, non-invasive screen for AD risk and progression.

Teaching what matters: Integrating health equity education into the core surgery clerkship

BACKGROUND

Significant disparities in surgical outcomes exist. It is imperative to prepare future doctors to eliminate disparities. Our team of senior medical students developed a surgical clerkship module examining equity in prostate cancer. Student attitudes before and after a facilitated teaching session were assessed.

METHODS

A surgical equity pilot module was integrated into the core surgical clerkship starting in July 2020. This module was composed of (1) asynchronous preparatory material and (2) a synchronous interactive case discussion regarding disparities in prostate cancer. Discussion sessions were facilitated by upper-level medical students. Participants answered optional anonymous Likert-style and open-ended survey questions before and after the session. Pre- and post-responses were compared.

RESULTS

One hundred and sixteen students completed the module between July 2020 and January 2021. Pre- and post-survey response rates were 66% and 29%, respectively. At baseline, almost all students (95%) agreed knowledge of disparities would make them a better physician. However, the majority (95%) described their general knowledge of surgical disparities as "nonexistent," "poor," or "average." Most students did not have a framework for assessing causes of surgical disparities (86%) and were not aware of interventions for reducing disparities (90%). After intervention, the majority rated their knowledge of surgical disparities as "good" or "excellent" (71%; P < .001). Most students indicated they had a framework 79%; P < .001) and were aware of effective interventions (62%; P < .001).

CONCLUSION

We demonstrated a successful pilot of an equity-focused clerkship module. Student attitudes after a single session reflected significant improvement in knowledge of causes and interventions related to surgical disparities. Equity-focused teaching can be incorporated into the surgical clerkship.

Clinically Significant Prostate Cancer Detection After A Negative Prebiopsy MRI Examination: Comparison of Biparametric Versus Multiparametric MRI

Background: The frequency of clinically significant prostate cancer (csPCa) following negative biparametric MRI (bpMRI) and multiparametric MRI (mpMRI) has not been well investigated in direct comparative studies. Objective: To compare the frequency of csPCa after negative prebiopsy bpMRI and mpMRI, and to evaluate factors that predict csPca in the two cohorts. Methods: This retrospective study included 232 men (mean age, 64.5 years) with negative bpMRI from August 2017 to March 2020 and193 men (mean age, 69.0 years) with negative mpMRI from January 2018 to December 2018, defining PI-RADS category of 1 or 2 as negative. Our institution offers bpMRI as a low-cost self-pay option for patients without insurer coverage of prebiospy mpMRI. Patient characteristics and subsequent biopsy results were recorded. csPCa was defined as Gleason score ≥3+4. Multivariable regression analyses were performed to identify independent predictors of csPCa. AUC of prostate specific antigen density (PSAD) for csPCA was computed, and diagnostic performance of PSAD was assessed at a clinically established threshold of 0.15 ng/mL2. Results: Systematic biopsy was performed after negative bpMRI in 41.4% (96/232), versus after negative mpMRI in 30.5% (59/193) (p=.02). Among those undergoing biopsy, csPCa was present in 15.6% (15/96) in the mpMRI cohort versus 13.6% (8/59) in the bpMRI cohort (p=.69). NPV for csPCa was 84% (81/96) for bpMRI and 86% (51/59) for mpMRI. In multivariable analyses, independent predictors of csPCa included smaller prostate volume (OR=0.27, p<.001) and greater PSAD (OR=3.09, p<.001). In multivariable models, bpMRI (compared with mpMRI) did not independently predict csPCa (p>.05). PSAD had AUC for csPCa of 0.77 (95% CI: 0.64, 0.89) in the bpMRI cohort versus 0.68 (95% CI: 0.42, 0.93) in the mpMRI cohort. For detecting csPCa, PSAD threshold of 0.15 ng/mL2 had NPV of 90% and PPV of 28%, in the bpMRI cohort, versus NPV of 92% and PPV of 44%in the mpMRI cohort. Conclusion: The frequency of csPCa was not significantly different on systematic biopsy performed after negative bpMRI and mpMRI examinations. PSAD had similar diagnostic utility for csPca in both cohorts. Clinical Impact: Either bpMRI or mpMRI, in combination with PSAD, can help avoid negative prostate biopsies.

The stanford prostate cancer calculator: Development and external validation of online nomograms incorporating PIRADS scores to predict clinically significant prostate cancer

BACKGROUND

While multiparametric MRI (mpMRI) has high sensitivity for detection of clinically significant prostate cancer (CSC), false positives and negatives remain common. Calculators that combine mpMRI with clinical variables can improve cancer risk assessment, while providing more accurate predictions for individual patients. We sought to create and externally validate nomograms incorporating Prostate Imaging Reporting and Data System (PIRADS) scores and clinical data to predict the presence of CSC in men of all biopsy backgrounds.

METHODS

Data from 2125 men undergoing mpMRI and MR fusion biopsy from 2014 to 2018 at Stanford, Yale, and UAB were prospectively collected. Clinical data included age, race, PSA, biopsy status, PIRADS scores, and prostate volume. A nomogram predicting detection of CSC on targeted or systematic biopsy was created.

RESULTS

Biopsy history, Prostate Specific Antigen (PSA) density, PIRADS score of 4 or 5, Caucasian race, and age were significant independent predictors. Our nomogram-the Stanford Prostate Cancer Calculator (SPCC)-combined these factors in a logistic regression to provide stronger predictive accuracy than PSA density or PIRADS alone. Validation of the SPCC using data from Yale and UAB yielded robust AUC values.

CONCLUSIONS

The SPCC combines pre-biopsy mpMRI with clinical data to more accurately predict the probability of CSC in men of all biopsy backgrounds. The SPCC demonstrates strong external generalizability with successful validation in two separate institutions. The calculator is available as a free web-based tool that can direct real-time clinical decision-making.

A Systematic Review for Health Disparities and Inequities in Multiparametric Magnetic Resonance Imaging for Prostate Cancer Diagnosis

RATIONALE AND OBJECTIVES

Multi-parametric Magnetic Resonance Imaging (mpMRI) is a novel procedure recommended by the American Urological Association for Prostate Cancer (PCa) diagnosis. In radiology, differences in utilization of expensive screening techniques are described but never reviewed for mpMRI. Thus, our article aims at summarizing disparities relating to the expensive yet revolutionary mpMRI in United States men with PCa while highlighting needed research areas.

MATERIAL AND METHODS

Eligible articles were gathered via PubMed query, referred publications known to the authors or from the reference lists of the identified publications. We excluded studies that didn't specifically evaluate mpMRI technique, weren't conducted in the United States, or didn't directly assess the relationship between disparities and mpMRI. No date restrictions were applied, resulting articles were published through 2020.

RESULTS

Out of 80 publications, 17 were selected. Two unique themes were identified: 1) disparities in mpMRI utilization, and 2) performance. While demographic factors such as race, age and socioeconomic status played a significant role in utilization, mpMRI demonstrated equal and sometimes superior performance in AAs.

CONCLUSION

Our findings illustrate the importance of disparity awareness in PCa mpMRI and highlight the need to examine additional mpMRI disparities across other races and social determinants. A new area of inequity in PCa was theoretically illustrated, as lower utilization of mpMRI was detected in a group that could potentially benefit from it the most. Major limitation was the selected search terms. Our review is unique as disparities related to mpMRI were found to be multilayered, affecting utilization and performance. Continued research is needed to discover additional areas in efforts to reduce disparity gaps related to mpMRI and PCa.

How does a prebiopsy mri approach for prostate cancer diagnosis affect prostatectomy upgrade rates?

BACKGROUND

To compare the pathologic upgrade and downgrade rates after radical prostatectomy (RP) between patients diagnosed by prebiopsy prostate MRI followed by a combination of systematic and fusion biopsy (ComBx) versus patients undergoing systematic biopsy only (SBx).

METHODS

A retrospective review of men undergoing RP at our institution between Jan 2014 and Mar 2020 was performed. These patients were separated into two independent cohorts based on two approaches: Patients receiving prebiopsy prostate MRI during initial evaluation and those who did not receive MRI. Patients with positive MRI findings underwent subsequent ComBx to confirm diagnosis while those without MRI underwent standard trans-rectal ultrasound (TRUS) guided systematic 12-core biopsy (SBx). Primary outcomes were rates of pathological upgrade (prostatectomy grade higher than grade determined at time of biopsy) and downgrade (prostatectomy grade lower than biopsy grade).

RESULTS

A total of 213 patients undergoing radical prostatectomy, 91 diagnosed via a prebiopsy MRI and ComBx approach and 122 diagnosed by a traditional SBx approach, were included in the study. There was no significant difference between age, PSA, or positive family history between the two cohorts. Of the 91 patients who received prebiopsy MRI, 88 patients were determined to have a PIRADS 4 or 5 lesion. Patients who received MRI and subsequent ComBx had a lower rate of any pathological upgrade after RP (9.89% vs. 22.13%, P = 0.018) without a significant difference in pathologic downgrade rate (28.57% vs. 18.85%, P = 0.095). On multivariable logistic regression, receiving prebiopsy MRI during initial evaluation was the single negative independent predictor of pathologic upgrade (OR = 0.23, P = 0.017). A prebiopsy MRI approach was also the single predictor of pathologic downgrade (OR = 3.13, P = 0.041).

CONCLUSIONS

Patients receiving prebiopsy MRI during prostate cancer evaluation were less likely to have their PCa upgraded. Furthermore, although diagnosis via MRI and subsequent ComBx was associated with an increased rate of downgrades after RP, relatively few resulted in a downgrade from clinically significant to clinically insignificant cancer.

A Comparison of Cancer Detection Rates Between Template Systematic Biopsies Obtained Using Magnetic Resonance Imaging-Ultrasound Fusion Machine and Freehand Transrectal Ultrasound-Guided Systematic Biopsies

Introduction: There are reports that the 12-core template systematic biopsies (SBx) obtained by using software registration machines (e.g., Artemis) have higher cancer detection rates (CDRs) of prostate cancer (PCa) than the standard, freehand 12-core transrectal ultrasound (TRUS)-guided biopsies. The goal of our study is to compare the clinically significant (CS) CDRs of SBx in two independent cohorts who underwent freehand TRUS-SBx alone (Cohort A) or machine-guided SBx as part of a combined MRI-ultrasound (MRI-US) fusion biopsy (FBx) (Cohort B). Materials and Methods: A retrospective review of all patients undergoing prostate biopsies over a 4-year period at the University of Cincinnati Medical Center was performed. CS cancer was defined as having a Gleason score ≥7. MRI-US FBx were obtained by using an Artemis software registration device (ARTEMIS™, Eigen, Inc., Grass Valley, CA). Statistical significance was considered at p < 0.05. Results: Nine hundred and thirty men underwent SBx (Cohort A: 474, Cohort B: 456). There were no statistical differences between cohort A and B in CS CDRs in the overall population (39.3% vs 33.8%; p = 0.093), biopsy naive patients (40.4% vs 39.8%; p = 0.951), or patients with a prior negative biopsy (22.7% vs 25.0%; p = 0.910). Multivariate logistic regression controlling for age, race, prostate-specific antigen level, prostate volume, abnormal digital rectal exam, and family history of PCa demonstrated comparable CS CDRs, which was maintained when further stratified by prior biopsy history (all patients: odds ratio [OR] 0.99, 95% confidence interval [CI] 0.71-1.38, p = 0.958; biopsy naive: OR 0.79, 95% CI 0.51-1.22, p = 0.291; prior negative biopsy: OR 0.64, 95% CI 0.21-1.75, p = 0.403). Conclusions: Our study did not find a significant difference in the CS CDRs of machine-guided SBx compared with the freehand TRUS-SBx. Unless the SBx is done at the time of FBx, the use of these machines for obtaining SBx only is unlikely to result in any increase of CS CDRs.